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2 Executive Summary Since its passage in 2010, the Affordable Care Act (ACA) has made tremendous progress in improving access to health insurance and health care for millions of Americans. Approximately 14.1 million previously uninsured Americans gained health insurance between the beginning of open enrollment in October 2013 and March 4, In fact, by that date, the share of Americans who were uninsured had dropped to 13.2 percent, compared to 20.3 percent at the end of 2013 the largest decrease in the number of uninsured since Some of the greatest declines in uninsured rates were for lower- and middle-income consumers, 2 including those eligible for tax credits to help pay their premiums for plans in the health insurance marketplaces. Data from the Department of Health and Human Services also show that more than 11 million people selected plans through the marketplaces, and more than 85 percent of these consumers qualified for premium tax credits. 3 But simply having health insurance is no guarantee that consumers can afford to pay for health care. Health insurance involves different types of costs that consumers must pay out of pocket ranging from a health plan s deductible to copayments at a doctor s office. These expenses add up, and research has shown that even nominal cost-sharing can deter people from getting needed care. 4 Unfortunately as our study shows for many Americans with non-group coverage, deductibles and other out-of-pocket costs are prohibitively high and are associated with many of these insured consumers forgoing needed health care. Our study examined adults who bought private health insurance in the non-group market in 2014 We analyzed data from the Urban Institute s Health Reform Monitoring Survey (HRMS) on adults who bought private, non-group health insurance (as opposed to having insurance from an employer or a public coverage program) for themselves or their families in Our study examines the following:»» The incomes of adults who bought insurance, as well as the deductibles for those adults, grouped by three income levels: percent of the federal poverty level, percent of poverty, and 400 percent of poverty and higher.»» Problems that adults experienced with being able to afford health care, grouped by these income levels: percent of poverty and 250 percent of poverty or more, and also grouped by the amount of their deductible. Simply having health insurance is no guarantee that consumers can afford to pay for health care. Unfortunately as our study shows for many Americans with non-group coverage, deductibles and other out-of-pocket costs are prohibitively high and are associated with many of these insured consumers forgoing needed health care. NON-GROUP SPECIAL REPORT HEALTH INSURANCE: / MAY 2015 MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 2

3 Executive Summary continued The Affordable Care Act has increased access to health This report analyzes the portion of adults who bought insurance and financial assistance for millions of non-group health insurance and who went without Americans. But even with the new assistance that helps needed medical care because they could not afford it or consumers pay their premiums and out-of-pocket health who faced high deductibles. It also includes an analysis of care costs, one-quarter of consumers who buy insurance the potential causes of these affordability issues, as well on their own still have problems being able to afford as recommendations that health insurers and state and needed care. federal governments can take to improve the affordability of consumers out-of-pocket health care costs. Income Levels of People Surveyed for This Report In this report, we present findings for adults who bought insurance in the non-group market people who bought health plans for themselves or their families (as opposed to having insurance from an employer or public coverage program). For several measures, we analyzed adults from two income groups and divided them accordingly: Adults with lower to middle incomes, who had family incomes between 139 and 249 percent of poverty (from $16,200 to $29,199 for an individual in 2014, or from $27,400 to $49,499 for a family of three). This group is eligible for two kinds of financial help in the health insurance marketplaces: They can get tax credits to lower their monthly premiums, and they qualify for cost-sharing reduction subsidies, which lower their deductibles, copayments, or total out-of-pocket expenses in marketplace plans. Adults with middle incomes, who had family incomes between 250 and 399 percent of poverty (from $29,200 to $46,699 for an individual in 2014, or from $49,500 to $79,199 for a family of three). People in this group are eligible only for premium tax credits to lower their monthly premiums. We excluded from our sample people who had family incomes at or below 138 percent of poverty, because that group is eligible for Medicaid in many states. Defining High Deductibles In this report, we define plans with high deductibles as plans with deductibles of $1,500 or more per person. The IRS defines high deductibles somewhat differently. For 2014, the IRS defined plans with high deductibles that could be used with health savings accounts as plans with deductibles of $1,250 or more for an individual and $2,500 or more for a family. In our study, $1,500 was the number that was closest to the $1,250 figure the IRS uses, which is why we chose that amount as the level for a high deductible. We call plans with deductibles of $3,000 or more per person plans with exceedingly high deductibles. However, consumers can have deductibles that are much higher: Plans that are sold to consumers in the non-group market can have deductibles that are as high as $6,600 for an individual in NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 3

4 Executive Summary continued The Affordable Care Act Is Making Health Insurance and Health Care More Affordable The Affordable Care Act (ACA) is having a measurable impact on Americans access to health insurance, particularly those with lower to middle incomes. Research has found that the number of uninsured in this country has reached historic lows since full implementation of the ACA s coverage provisions. 5 This is in large part due to the availability of new financial assistance to help lower- and middle-income individuals and families afford private, non-group insurance through the marketplaces, as well as to the expansion of Medicaid to low-income adults in 28 states plus the District of Columbia. 6 And our own findings bear this out: The share of people with non-group insurance who have lower to middle incomes jumped by more than 10 percentage points from 2013 to 2014, a sign that people are seeking out and using the health care law s premium tax credits and other financial assistance. We also found that more individuals with non-group coverage had no deductible in 2014 compared to 2013 (the percentage nearly tripled), and that marketplace insurance is making out-of-pocket costs more affordable for many. Report findings 1 In 2014, the proportion of insured adults with lower to middle incomes increased (see Table 1). In 2014, the first year that financial assistance was available in the marketplace to make insurance more affordable, more people who bought insurance on their own had lower to middle incomes. The proportion of non-group adult enrollees who had lower to middle incomes increased from about one-quarter (25.4 percent) in 2013 to more than one-third (36.9 percent) in Among adults who bought non-group insurance: More adults who bought non-group insurance had no deductible in 2014 than in 2013 (see Table 2). The percent of adults with non-group insurance who had zero deductible nearly tripled, jumping from 3.6 percent in 2013 to 10.6 percent in Adults who bought their insurance in the marketplace were less likely to have high 3 deductibles or exceedingly high deductibles than those who bought their insurance outside the marketplace (see Table 3). High deductibles: 42.8 percent of adults with non-group insurance in the marketplace reported having high deductibles of $1,500 or more per person, compared to 58.3 percent of adults with non-group insurance outside the marketplace. Exceedingly high deductibles: 22.5 percent of adults with non-group insurance in the marketplace reported having exceedingly high deductibles of $3,000 or more per person, compared to 37.5 percent of adults with non-group insurance outside the marketplace. However, as further discussed in the Methodology, some of the magnitude of these differences could be attributable to difficulties in how marketplace enrollees were identified in our survey data. We did more testing on questions to see if errors in survey responses could account for the change. While we could not be sure of the exact percentages of people who had no deductible in 2014, we continued to find that the increase was statistically significant, probably due to the availability of zero dollar deductible plans in the marketplace. 7 Note: Unless otherwise noted, all of the adults referenced in our findings have incomes above 138 percent of poverty. see tables on page 28 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 4

5 Executive Summary continued One-Quarter of Health Care Consumers with Non-Group Insurance Still Have Problems Affording Care Our data also show that many Americans with non-group insurance still have problems being able to afford needed care. Just over one-quarter of adults who were insured for a full year still reported that they went without needed medical care during that year because they could not afford it. People with lower to middle incomes were more likely to forgo medical care due to affordability issues than people with higher incomes (those with incomes at or above 250 percent of poverty). Furthermore, we found that people with highdeductible health plans were more likely than those with lower deductibles to forgo care. These high-deductible plans are common, even among those with lower to middle incomes: Our analysis found that nearly two in five lower- to middle-income adults had deductibles of $1,500 or more per person. Report findings Just over one-quarter (25.2 percent) of adults who were insured for a full 4 year went without needed medical care because they could not afford it (excluding dental care, see Table 4). The two most common types of care that adults went without were: Tests, treatments, and follow-up care: 15.3 percent went without needed tests or follow-up care Prescription drugs: 14.2 percent went without needed medications 5 Adults with lower to middle incomes were the most likely to forgo needed medical care (excluding dental care, see Table 5). For lower- to middle-income adults who were insured for a full year, 32.3 percent didn t get needed medical care because they could not afford it. For adults with middle or higher incomes (at or above 250 percent of poverty), a lower number 22.2 percent didn t get needed medical care because they could not afford it. 6 Adults with high deductibles were more likely to forgo needed medical care (excluding dental care, see Table 6). For adults with deductibles of $1,500 or more per person who were insured for a full year, 29.8 percent went without needed medical care because they could not afford it. For adults with deductibles under $1,500 per person, only 19.6 percent went without needed medical care because they could not afford it. 7 Among adults who bought non-group insurance: In 2014, half (50.6 percent) of adults had high deductibles of $1,500 or more, and 30 percent had exceedingly high deductibles of $3,000 or more (see Table 7). Of adults with lower to middle incomes, 39.3 percent had high deductibles of $1,500 or more per person, and 22 percent had exceedingly high deductibles of $3,000 or more per person. And for middle-income adults, 53.2 percent had high deductibles of $1,500 or more per person, and 29.9 percent had exceedingly high deductibles of $3,000 or more per person. Note: Unless otherwise noted, all of the adults referenced in our findings have incomes above 138 percent of poverty. see tables on page 31 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 5

6 Introduction Consumers who buy health insurance in the nongroup market saw many welcome changes in 2014, including several consumer protections. Many of these protections apply to insurance bought both inside and outside the health insurance marketplaces established by the Affordable Care Act (see sidebar). But even with these changes, insured consumers may still have problems being able to afford care or understand their health plan s benefits. They may face high deductibles before their plans begin to pay for any care beyond preventive services. And after meeting their deductibles, they may still have to pay steep copayments and co-insurance until they reach their annual limit on out-of-pocket expenses. In addition, many consumers continue to struggle to understand the benefits and costs associated with their insurance. We undertook this study to examine the portion of adults with non-group insurance who had high deductibles, difficulty affording care, and trouble understanding how to use their health insurance in 2014 the first year the marketplaces were fully operational. Using survey data collected in September 2013, September 2014, and December 2014 through the Urban Institute s quarterly Health Reform Monitoring Survey, we examined coverage, deductibles, reported problems with affording health care, and the ability to understand health insurance among adults with non-group coverage. We compared data across adults of various income levels, and, for some measures, between adults with marketplace coverage and adults with non-group coverage outside the marketplace. Insurance Improvements for Consumers Who Buy Non-Group Coverage Consumer protections that apply to insurance sold both inside and outside the marketplaces: Insurance companies can no longer deny coverage to people with pre-existing conditions or charge them higher premiums. Health plans must cover a more comprehensive scope of health care services and cover certain preventive services with no cost-sharing. There are annual limits on the most an individual or family has to pay out of pocket for covered benefits that are provided through their plan s network. Health plans are classified as platinum, gold, silver, or bronze based on their level of cost-sharing, which helps consumers understand how generous a plan s coverage is. Benefits that apply only to plans sold in the marketplaces: Consumers with lower and middle incomes may qualify for tax credits to help pay for premiums. Consumers with lower to middle incomes may also qualify for cost-sharing reduction subsides that lower their out-of-pocket costs for covered services. Marketplace websites provide new tools to help consumers compare plans and learn about insurance. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 6

7 Abridged Methodology We contracted with the Urban Institute to analyze data from the Health Reform Monitoring Survey (HRMS) collected in September 2013, September 2014, and December 2014 regarding people who bought non-group individual or family health insurance. This quarterly survey is designed to provide timely information about implementation issues in the Affordable Care Act and about changes in insurance. The questions in the HRMS are often based on questions used in federal government surveys. More information about the survey is available online at We asked the Urban Institute to analyze data on non-elderly adults with non-group insurance (that is, insurance people bought for themselves or their families, rather than insurance people get through their employers or a public coverage program), including data on their deductibles and access to care. We limited our analysis to respondents with incomes above 138 percent of poverty for two reasons: First, this is the primary population that the Affordable Care Act is designed to help afford non-group insurance. And second, we wanted to be sure respondents were not confusing non-group insurance with Medicaid (which is available to consumers with incomes up to 138 percent of poverty in states that have expanded Medicaid under the Affordable Care Act). We also limited our analysis of adults not getting needed care to adults who did not get needed medical care excluding dental care. This is because health plans typically do not cover dental care for adults, and the primary focus of our analysis is assessing the problems consumers have being able to afford covered care due to cost-sharing. Adults inability to afford dental care may be due to their not having any dental coverage rather than to problems with affording the cost-sharing associated with their health plan. The Urban Institute tested all reported data for significance and reviewed this report for accuracy. For the full methodology, including key assumptions and limitations, see page 24. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 7

8 I. The Affordable Care Act Is Making Health Insurance and Health Care More Affordable Since the full implementation of the Affordable Care Act s coverage provisions, there have been landmark improvements in people s access to affordable health insurance and health care. As we noted earlier, surveys have found that the number of uninsured in this country has dipped to an historic low since the ACA was fully implemented. Our findings also show notable improvements related to the affordability of health coverage and care for those buying insurance on their own in A greater portion of adults with non-group insurance had lower to middle incomes, and more people with non-group insurance had no deductible whatsoever in This is an encouraging sign that the affordability of both coverage and care is improving for some consumers. People with marketplace insurance also were less likely to have high deductibles than people buying insurance on their own outside the marketplace in This underscores the enhanced value that marketplace coverage is providing to consumers, particularly those who qualify for financial assistance to help with cost-sharing in marketplace plans. Section findings Among adults who bought non-group insurance: 1 In 2014, the proportion of insured adults with lower to middle incomes increased (see Table 1). In 2014, the first year that financial assistance was available in the marketplace to make insurance more affordable, more people who bought insurance on their own had lower to middle incomes. The proportion of non-group adult enrollees who had lower to middle incomes increased from about one-quarter (25.4 percent) in 2013 to more than one-third (36.9 percent) in More adults who bought non-group insurance had no deductible in 2014 than in 2013 (see Table 2). The percent of adults with non-group insurance who had zero deductible nearly tripled, jumping from 3.6 percent in 2013 to 10.6 percent in Adults who bought their insurance in the marketplace were less likely to have high deductibles or exceedingly high deductibles than those who bought their insurance outside the marketplace (see Table 3). High deductibles: 42.8 percent of adults with non-group insurance in the marketplace reported having high deductibles of $1,500 or more per person, compared to 58.3 percent of adults with non-group insurance outside the marketplace. Exceedingly high deductibles: 22.5 percent of adults with non-group insurance in the marketplace reported having exceedingly high deductibles of $3,000 or more per person, compared to 37.5 percent of adults with non-group insurance outside the marketplace. However, as further discussed in the Methodology, some of the magnitude of these differences could be attributable to difficulties in how marketplace enrollees were identified in our survey data. We did more testing on questions to see if errors in survey responses could account for the change. While we could not be sure of the exact percentages of people who had no deductible in 2014, we continued to find that the increase was statistically significant, probably due to the availability of zero dollar deductible plans in the marketplace. 7 Note: Unless otherwise noted, all of the adults referenced in our findings have incomes above 138 percent of poverty. see tables on page 28 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 8

9 Financial assistance is helping lower- to middle-income adults afford insurance The share of adults buying coverage on their own who had lower to middle incomes rose by more than 10 percentage points from 2013 to That s an important finding because people in this income group are the least likely to be able to afford the full cost of private insurance on their own. And that s precisely why the Affordable Care Act provides generous premium tax credits to this population. This finding is an encouraging sign that the ACA s financial assistance is truly helping more lower- to middle-income Americans afford insurance on their own. We are hopeful that the increased proportion of nongroup enrollees with lower and middle incomes is a sign that the disparity in access to coverage is closing. The Census Bureau s Current Population Survey shows that before the Affordable Care Act, people with incomes below 250 percent of poverty were less likely to have private insurance (that is, insurance either through a job or through buying non-group coverage) than people at higher income levels, and they were more likely to be uninsured. 8 More adults have zero deductible, meaning they face one less potential barrier to care The percent of adults with non-group insurance that had zero deductible significantly increased from 2013 to 2014, rising from 3.6 percent in 2013 to 10.6 percent in Deductibles, which require people to pay the full cost of care on their own up to a certain amount, can pose significant barriers to getting necessary care for people who can t afford to pay the full cost of care on their own. Adults faced higher deductibles outside the marketplace Deductible amount $3,000+ $1,500+ $1,500 - $2,999 $1 - $1,499 $0 Percentage of adults who bought non-group insurance in the health insurance marketplace and outside the marketplace who had that deductible amount % of adults inside the marketplace 38% of adults outside the marketplace Note: 0.2% of respondents did not report a deductible amount, and 1.6% were not sure of their deductibile amount. Source: Urban Institute, 2014 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 9

10 Research has shown that even nominal cost-sharing can deter people from getting needed care. 9 Given this, it is welcome news that more people buying insurance on their own do not have to worry that their deductible could make it difficult for them to be able to afford the care they need. The increased availability of plans with no deductible may be due in part to the new cost-sharing reduction subsidies that reduce out-of-pocket costs (like deductibles) for lower- to middle-income people with marketplace insurance. We know from other data that a number of marketplace plans available to people with family incomes below 150 percent of poverty had no deductibles after cost-sharing reduction subsidies were applied. 10 Marketplace coverage provides better value to consumers in many ways: Financial assistance that lowers premiums and cost-sharing and new tools to help consumers make informed choices about which plan to buy. Marketplaces are making the greatest strides in improving affordability We also found that the health insurance marketplaces are making the biggest strides in improving the affordability of cost-sharing. People buying insurance inside the marketplace were significantly less likely to have high deductibles (deductibles of $1,500 or more per person) or exceedingly high deductibles (deductibles of $3,000 or more per person) than those buying insurance outside the marketplace. This makes sense: Marketplace coverage provides better value to consumers in many ways. Financial assistance to lower premiums and cost-sharing is available only to those with marketplace insurance. Marketplaces also include new tools consumers can use to compare coverage based on plans out-of-pocket costs, which can help them make informed choices about which plan to buy. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 10

11 II. One-Quarter of Health Care Consumers with Non-Group Insurance Still Have Problems Affording Care Even with the historic gains made by the Affordable Care Act, many Americans with non-group insurance still have problems being able to afford needed care. Just over onequarter of adults who were insured for a full year still went without needed medical care (excluding dental care) during that year because they could not afford it. People with lower to middle incomes were more likely to forgo medical care due to affordability issues than people with incomes above 250 percent of poverty. Furthermore, we found that people with highdeductible health plans were more likely than those with lower deductibles to forgo care. These high-deductible plans are common, including among those with lower to middle incomes: Our analysis found that nearly two in five lower- to middle-income adults had high deductibles of $1,500 or more per person. Section findings Among adults who bought non-group insurance: 4 Just over one-quarter (25.2 percent) of adults who were insured for a full year went without needed medical care because they could not afford it (excluding dental care, see Table 4). The two most common types of care that adults went without were: Tests, treatments, and follow-up care: 15.3 percent went without needed tests or follow-up care Prescription drugs: 14.2 percent went without needed medications 5 Adults with lower to middle incomes were the most likely to forgo needed medical care (excluding dental care, see Table 5). For lower- to middle-income adults who were insured for a full year, 32.3 percent didn t get needed medical care because they could not afford it. For adults with middle or higher incomes (at or above 250 percent of poverty), a lower number 22.2 percent didn t get needed medical care because they could not afford it. 6 Adults with high deductibles were more likely to forgo needed medical care (excluding dental care, see Table 6). For adults with deductibles of $1,500 or more per person who were insured for a full year, 29.8 percent went without needed medical care because they could not afford it. For adults with deductibles under $1,500 per person, only 19.6 percent went without needed medical care because they could not afford it. 7 In 2014, half (50.6 percent) of adults had high deductibles of $1,500 or more, and 30 percent had exceedingly high deductibles of $3,000 or more (see Table 7). Of adults with lower to middle incomes, 39.3 percent had high deductibles of $1,500 or more per person, and 22 percent had exceedingly high deductibles of $3,000 or more per person. And for middle-income adults, 53.2 percent had high deductibles of $1,500 or more per person, and 29.9 percent had exceedingly high deductibles of $3,000 or more per person. Note: Unless otherwise noted, all of the adults referenced in our findings have incomes above 138 percent of poverty. see tables on page 31 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 11

12 Even adults who were insured for a full year had to go without needed medical care because they could not afford their out-of-pocket costs for care Overall, 25.2 percent of adults who were insured for a full year didn t get needed care (excluding dental care) during the year because they could not afford it. Medical tests, treatments, and follow-up care were the most common types of care that adults had to forgo, followed by prescription drugs. For adults who were insured for a full year, 15.3 percent did not get needed medical tests, treatment, or follow-up care because they could not afford it, and 14.1 percent did not get needed medication because they could not afford it. It is critically important that consumers be able to afford all of these types of care. Not getting recommended follow-up care to treat an illness or not taking needed medications can result in people facing avoidable, more serious health problems and more expensive health care costs down the road. For people with chronic conditions, consistently taking necessary medications and getting recommended tests can be vital to managing their condition. Other research has found that insurers are designing many marketplace plans in ways that could impede access to these types of care. For example, silver marketplace plans often require that people meet a large deductible before the plan covers any care except for preventive care. Furthermore, nearly half of silver plans have a single deductible that applies to both medical and drug costs. 11 These types of benefit designs can make being able to afford necessary prescription drugs and follow-up care more difficult for people who cannot afford to pay all or most of the cost of such care on their own. A more consumer-friendly benefit design would have two smaller deductibles, including a small deductible for drugs and a separate deductible for other health care. Consumer-friendly plans could also be similar to many employer-based plans, which are more likely to cover some services, such as doctor visits, even before enrollees pay the full deductible in 4 adults with non-group coverage went without some needed health care because they could not afford the cost. 1in4 Silver marketplace plans, a popular choice with consumers, often require that people meet a large deductible before the plan covers any care except for preventive care. A more consumer-friendly benefit design would cover some services even before enrollees pay the full deductible. Types of health care that adults with non-group coverage went without (by percent of adults)* Tests, treatment, or follow-up care Prescription drugs Medical care General doctor Specialist 12% 12% 11% 15% 14% *Adults who bought non-group health insurance in 2014 and who were insured for the past 12 months. Source: Urban Institute, 2014 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 12

13 Adults with lower to middle incomes have the most trouble affording some medical costs Lower- to middle-income adults who were insured for the full year were significantly more likely than those with higher incomes to forgo needed care because they could not afford it: Nearly one-third (32.3 percent) of lower- to middle-income adults didn t get needed medical care (excluding dental care) because they could not afford it. This population has income that would qualify it for financial assistance to reduce cost-sharing in marketplace insurance. For some, that extra help reduces their deductibles. But for others in this income group, the extra help reduces only the maximum annual out-of-pocket limit that they would face in a year. As our findings show, even with cost-sharing assistance, some lower- to middle-income consumers still found their out-of-pocket costs for covered care to be unaffordable during the previous 12 months. But middle- and higher-income adults also struggle to afford medical costs Among adults with incomes at or above 250 percent of poverty (who do not qualify for financial assistance with cost-sharing), more than one-fifth (22.2 percent) didn t get some needed care because they could not afford it. While lower- to middle-income adults have the most difficulty with out-of-pocket costs, this finding clearly shows that many consumers with incomes at or above 250 percent of poverty also struggle to afford their cost-sharing for medical care that is covered by their plan. High deductibles are associated with barriers to health care Our analysis found that adults who had deductibles of $1,500 or more per person were more likely than those with lower deductibles to forgo needed care (excluding dental care) because they could not afford it. Previous research has also found that high deductibles can create barriers that prevent consumers from getting needed care, particularly for consumers with lower incomes. Most notably, a recent Commonwealth Fund report found that people with deductibles that exceeded 5 percent of their income were more likely to delay or forgo needed care due to cost than those with lower deductibles relative to their income. 14 Insured adults with lower to middle incomes frequently went without needed care Percentage of adults at these income levels who went without some care 32% 22% lower- to middle-income adults insured all year middle- to high-income adults insured all year Source: Urban Institute, 2014 A recent Commonwealth Fund report found that people with deductibles that exceeded 5 percent of their income were more likely to delay or forgo needed care due to cost than those with lower deductibles relative to their income. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 13

14 Table 8. Combined Cost of Deductibles and Premiums for a Single Individual with Non-Group Health Insurance, 2014 INCOME DEDUCTIBLE AMOUNT DEDUCTIBLE AS A PERCENT OF INCOME PREMIUM CONTRIBUTION AS A PERCENT OF INCOME PREMIUM CONTRIBUTION AMOUNT COMBINED ANNUAL COST AS A PERCENT OF INCOME COMBINED ANNUAL AMOUNT $29,200 MIDDLE INCOME (250% of poverty) $1, % 8.05% $2, % $3,851 $3, % 8.05% $2, % $5,351 Source: Families USA s estimate of the premium contribution for an adult with income at 250 percent of poverty is based on the percent of income the federal government expected consumers with this income to spend on premiums for a second least-expensive silver plan in This means that lower- and middle-income adults are particularly likely to forgo needed care when faced with deductibles that exceed $1,500 or, even more problematic, $3,000. For these consumers, high and exceedingly high deductibles take up a relatively larger portion of their income compared to consumers with higher incomes (see Table 8 and the graphic on page 15). Proponents of high deductibles argue that because high-deductible plans require consumers to pay more of their medical costs up front, these plans give consumers an incentive to use health care more wisely. However, our findings and previous research tell a different and more troubling story: High deductibles are associated with consumers having difficulty getting the care they need. A significant number of adults have high deductibles that could be unaffordable We also found that a substantial number of adults with lower to middle incomes still faced high deductibles (deductibles of $1,500 or more) that could be unaffordable and could prevent them from getting needed care. Among adults with lower to middle incomes, nearly two in five (39.3 percent) had deductibles that were $1,500 per person or higher. And more than one in five (22 percent) had deductibles that were $3,000 per person or higher. Among middle-income adults, more than half (53.2 percent) had deductibles of at least $1,500 per person, and nearly one in three (29.9 percent) had exceedingly high deductibles of $3,000 or more per person. As discussed in the previous section, our own findings and previous research suggest that deductibles of this magnitude can create problems obtaining needed care, particularly for lower- and middle-income consumers. Recent research has also found that less than half of people with private insurance who have incomes between 100 and 250 percent of poverty have financial assets that are adequate to cover a deductible of even $1,200 for an individual. 15 It is important to note that not everyone needs enough health care that they would end up paying all of a NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 14

15 The Combined Cost of Premiums and Deductibles Can Eat Up a Substantial Portion of People s Income Covering the cost of a high deductible in addition to premiums can be a substantial financial burden for lower- to middle-income consumers. These graphics illustrate the scope of problems deductibles pose for consumers. To calculate premiums for these adults, we used the percent of income the federal government expects consumers to spend on premiums for a second least-expensive silver plan. 2 Insured adults with higher deductibles are more likely to go without needed care Percentage of adults at these deductible levels who went without some care Deductible amount $1,500+ under $1,500 20% 30% Source: Urban Institute HRMS, September and December How high deductibles and premiums can add up for a middle-income individual 3 Significant portions of lower- and middleincome adults face high deductibles Middle-income individual with marketplace coverage Percentage of adults at these income levels who had high deductibles Annual income middle-income adult (250% of poverty) + Deductible: Annual premium contribution after premium tax credits: Individual s combined cost of deductible + annual premium: $29,200 $1,500 $2,351 (5.14% of income) (8.05% of income) $3,851 (13.19% of income) $3,000 $2,351 (10.27% of income) (8.05% of income) $5,351 (18.32% of income) lower- to middle-income adults middle-income adults $3,000+ lower- to middle-income adults middle-income adults Deductible amount $1, % 30% 39% 53% Source: Families USA, 2014 Source: Urban Institute HRMS, September and December 2014 NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 15

16 $1,500 or $3,000 deductible. But lower- and middleincome adults who do have high health care costs would spend a substantial portion of their income on meeting their deductible in addition to paying their premium before their plan would help pay for needed care (see Table 8). For example:»» For a single adult making $29,200 (250 percent of poverty), a deductible of $1,500 plus what he or she is expected to pay in premiums for a silver plan, after premium tax credits, constitutes more than 13 percent of his or her income.»» With a $3,000 deductible, that same adult would have to pay more than 18 percent of his or her income toward premiums for a silver plan and the deductible. The bottom line: Our findings show that too many lower- and middle-income consumers face deductibles that are likely unaffordable relative to their income and that could create barriers to them getting the care they need. Too Many Adults Continue to Go Without Dental Care Access to dental coverage and care is one of the most persistent problems for many adults. The Affordable Care Act made dental care a required benefit for children s insurance, but it did not extend this requirement to insurance for adults. Therefore, many adults who buy non-group insurance may still have no dental coverage. In 2008, nearly 70 percent of people who bought health insurance on their own did not have dental coverage. 13 Without dental coverage, many adults struggle to get the dental care they need. Our primary analysis excluded reports of forgoing needed dental care (see the Methodology on page 24). However, the Urban Institute s Health Reform Monitoring Survey does ask people whether they went without needed dental care because they could not afford it. We examined reports of adults not getting needed dental care, and the findings were striking: Dental care was the most common type of health care service adults went without due to affordability issues. Nearly one in four (24 percent of) adults who were insured for a full year reported not getting needed dental care during the year due to affordability issues. While those with lower to middle incomes were most likely to have trouble affording this care, even among adults with incomes at or above 250 percent of poverty, it was still the most common type of care that they had to forgo because they could not afford it (see Table 5). This finding underscores the need to address the dental coverage gap in this country. Moving forward, it is critical that Congress requires all marketplace plans to include adult dental coverage. Without policies that expand access to affordable dental coverage to all adults, many adults will continue to be unable to afford the dental care they need. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 16

17 Do high-deductible plans help consumers make better ( high-value ) decisions about their health insurance? Proponents of high-deductible plans assert that making consumers spend more to cover their medical care will induce them to seek high-value care. But this is not possible for the many consumers who do not have the tools or the basic understanding of how their health insurance works in order to make informed decisions about what care to get at what price. Health insurance is complex. Not only is it difficult for any consumer to understand the complexities of his or her insurance and the resulting health care costs, but consumers who struggle with literacy or whose primary language is not English face even greater barriers. About 25 million Americans have limited English proficiency. a Without an understanding of what they will have to pay out of pocket, consumers may buy plans that have low monthly premiums but that also have high deductibles that are difficult to afford and that don t meet their needs. And once enrolled, consumers who are uncertain about their out-of-pocket costs can experience problems with paying medical bills or may need to forgo care. The Affordable Care Act provides new tools, such as a short summary of benefits and coverage, that are designed to help consumers understand what care is covered by their plan and how much they may need to pay for care. However, it is still a big leap to assume that consumers are able to determine their costs. In our study, about a quarter of survey respondents for quarters three and four of 2014 lacked the confidence that they could determine: whether a service was covered which drugs were covered or what they would cost the maximum they could be charged out of pocket for covered services in their health plan And about a third of respondents were not confident that they could figure out what costs counted toward their deductible. These findings are consistent with previous research on health insurance literacy. b,c a. U.S. Census Bureau, Year American Community Survey, available online at pages/productview.xhtml?pid=acs_13_5yr_dp02&prodtype=table. b. Kathryn Paez and Coretta Mallery, A Little Knowledge Is a Risky Thing: Wide Gaps in What People Think They Know about Health Insurance and What They Actually Know (Washington: American Institutes for Research, October 2014), available online at Health%20Insurance%20Literacy%20brief_Oct%202014_amended.pdf. c. Mira Norton, Liz Hamel, and Mollyann Brodie, Assessing Americans Familiarity with Health Insurance Terms and Concepts (Washington: Kaiser Family Foundation, November 2014), available online at NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 17

18 III. Why are people still struggling with out-of-pocket costs? The Affordable Care Act provides critical financial assistance to lower- and middleincome individuals and families to help them afford both coverage and care in the marketplace. However, our findings show that a substantial portion of people with non-group coverage, including some who may be eligible for this financial assistance, continued to have trouble being able to afford care. There are multiple factors that are likely contributing to affordability problems in the non-group market. We discuss the three most salient factors. In the federally facilitated marketplaces, more than three out of four people who received premium tax credits bought silver plans in Premium tax credits are tied to silver plans, which often have cost-sharing that is too high for many consumers to be able to afford Premium tax credits are designed for lower- and middleincome consumers to help them pay their monthly premiums. These tax credits are benchmarked to silver level plans: The formula for calculating the amount of tax credits is intended to assure that people who buy a typical silver plan will not have to pay more than an affordable percentage of their income on premiums. Although consumers are allowed to use these tax credits to cover the cost of more generous (and more expensive) gold or platinum plans, most lower- to middle-income consumers cannot afford to buy these more expensive plans. This is likely one reason why silver plans are the most popular type of plan. For example, in the federally facilitated marketplaces, more than three out of four people who received premium tax credits bought silver plans in Because these tax credits are designed to help a population with lower and middle incomes, it is equally important to keep these consumers cost-sharing amounts (deductibles and other out-of-pocket costs) Because these tax credits are designed to help a population with lower and middle incomes, it is equally important to keep these consumers cost-sharing amounts (deductibles and other out-of-pocket costs) low. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 18

19 low. Consumers with low to middle incomes can get help with reducing their cost-sharing in a silver plan through cost-sharing reductions. This help reduces cost-sharing a great deal for people with incomes below 200 percent of poverty (about $23,500 for an individual), and it reduces cost-sharing somewhat for people with incomes up to 250 percent of poverty (about $29,200 for an individual). But these reductions are not available to middleincome consumers. And if middle-income consumers cannot get help that reduces those high cost-sharing amounts in silver plans, these consumers can still face unaffordable deductibles and other out-of-pocket costs: The estimated average deductible of silver plans in 2014 was between $2,267 and $3, Only a portion of the lower-income consumers who are eligible for subsidies to reduce costsharing in silver plans receive substantial help to also reduce their deductibles People with incomes between 100 and 250 percent of poverty qualify not just for premium tax credits, but also for cost-sharing reduction subsidies that lower the out-of-pocket costs associated with silver plans. Of this group:»» People with incomes below 200 percent of poverty qualify for assistance that greatly reduces their out-of-pocket maximum in silver plans, as well as the specific amounts they must pay in upfront cost-sharing for care, like deductibles, copayments, and co-insurance.»» People with incomes between 200 and 250 percent of poverty are eligible only for more limited assistance, which significantly reduces their out-of-pocket maximum but provides only minor assistance with the amounts of upfront cost-sharing. Avalere, a public policy research firm that has conducted extensive analyses of marketplace plan offerings, has estimated that the average deductible of silver plans offered in the marketplace to people with incomes between 200 and 250 percent of poverty, after accounting for cost-sharing reductions, was $2,342 in This shows that even some consumers who receive help with cost-sharing may still find their out-ofpocket costs for care to be unaffordable. 3. Insurers are choosing to design silver plans with upfront cost-sharing that is too high for lower- and middle-income consumers to afford As we noted earlier, many insurers are offering silver plans that have high deductibles. In addition, many of these plans don t help pay for even basic primary care and medications before the consumer pays the full cost of his or her deductible. 19 This can make highdeductible plans particularly problematic for lowerand middle-income consumers. Due to federal requirements that govern the way silver plans are designed, these plans must have higher cost-sharing for more extensive or complex medical care. However, insurers do have the flexibility to design silver plans that charge low cost-sharing Only a portion of the lower-income consumers who are eligible for subsidies to reduce cost-sharing in silver plans receive substantial help to also reduce their deductibles. NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 19

20 for basic outpatient care like primary care visits, some prescription drugs, blood work, diagnostic testing, and secondary preventive services (services that help manage chronic conditions like diabetes or asthma). The main ways insurers can do this is by exempting these types of services from the deductible (meaning that the health plan helps pay for these services even before the deductible is fully paid) and by charging low copayments for this type of care. Insurers also can design silver plans with low or no deductible. Unfortunately, not enough insurers are taking advantage of that flexibility. This means that many lower- and middle-income consumers with silver plans may still struggle to get the basic care they need because they are not able to afford to pay the full cost of a doctor visit or medication out of pocket. Designing Silver Health Plans that Are More Affordable for Lower- and Moderate-Income Consumers In the health insurance marketplaces, low- and moderate-income consumers who use premium tax credits tend to buy silver plans. But recent analyses show that these types of plans typically have high deductibles. Our original research shows that it doesn t have to be this way insurers can choose to create silver plans with upfront cost-sharing amounts that are lower than those in highdeductible plans. Our brief, Designing Silver Health Plans with Affordable Out-of-Pocket Costs for Lower- and Moderate-Income Consumers (http://familiesusa.org/silver-plan-design), features: original research identifying existing silver plan designs that make the upfront cost for care more affordable policy and advocacy strategies to help advocates and policy makers effectively promote similar plan designs in other marketplaces across the country NON-GROUP HEALTH INSURANCE: MANY INSURED AMERICANS WITH HIGH OUT-OF-POCKET COSTS FORGO NEEDED HEALTH CARE 20

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